Sunday, 6 May 2007

The longer I work as a doctor, the less patience and sympathy I have for alcoholics. If ever there was a group of people who are self-absorbed, manipulative, lying ingrates who abuse and manipulate the people around them, their families and the healthcare system - it’s them.

I used to feel sorry for alcoholics. I used to listen to their stories about how life is so hard for them and about how nobody cared about them and about how they are really going to change and I used to feel sympathetic. But honestly, the more I see the way they constantly drain the will of those who are trying to help them, the less I feel sympathetic and the more I feel (whisper it) disdain.

Joy is a 44 year old woman who came to Medical Admissions today from A&E. Joy has alcoholic neuropathy. Basically, she’ drunk so much that she’s killing the nerves in her feet and this means her legs are weak and she falls over a lot. Joy has come into hospital because she couldn’t get up and started having alcohol withdrawal symptoms because she couldn’t get to her vodka. The physical symptoms of alcohol withdrawal can be treated quite easily and very effectively – this was not the issue.

Scratch the surface and I find out that in the last 7 days, Joy has called the ambulance out 3times and her GP out twice, each time refusing treatment when the health professionals arrive.

Joy’s mother, Evelyn, and Joy’s two children ask to speak to me. The story comes out that Joy has had many, many admissions to hospital recently because of her drinking. Each time, she comes in, her symptoms get sorted out and when she’s discharged, Joy is fine for about three or four days. Then Joy will start drinking again. When Joy drinks, she doesn’t look after herself, she doesn’t clean or wash herself, she dangerous when she tries to cook, she doesn’t eat and she gets verbally and physically abusive towards her own family. Evelyn is in her seventies and is not in the best of health herself. She is coming to the end of her tether because she just doesn’t know what to do with Joy. Evelyn is up all night worrying about her daughter. Worrying that Joy is going to hurt herself or that Joy is going to accidentally set fire to her block of flats.Evelyn, along with Joy’ children asked me if there was any way that we could detox Joy and get her better so that she’s the daughter (and mother) that she once was.

The trouble is, and I explained this to Evelyn, if Joy doesn’t want to stop drinking, there’s not a great deal we can do. Sure, we can patch her up when she falls down but unless she’s made her own mind up to give up the booze, any help we try to give will be wasted. Is there any point making her an appointment to see a behaviour specialist if she never turns up because she’s pissed again?

It’s sad. Here I a woman in her mid-forties who has family that obviously care about her and love her, but Joy doesn’t see that. Joy doesn’t care. This is what is going to happen: Eventually, Joy will drive them away and her family will give up on her. In the future, Joy will be in hospital telling young doctors like me about how her life is so hard and how nobody cares about her and how she’s really trying to change.

Joy is drinking her life away and it’s so sad.

A bit later on, I was siting a canula in Joy’s arm so we could give her some intravenous vitamins to help improve her symptoms and she says to me.

“You just don’t think that this (weak legs) is going to happen to you, do you doctor?”

I could not believe that she actually said that. I looked her in the eyes and said.

“Joy, you KNOW why this happens. You’ve been told again and again why this happens. It’s happening because you keep drinking. How many times have you been to hospital or A&E this year because of your drinking? How many times have you been told you need to stop? You’ve been told by doctors, by nurses, by your own FAMILY to stop drinking but you just carry on. Your legs are weak because the booze is rotting the nerves in your feet. Soon, it’ll start rotting your brain as well. You are 44 years-old! You should be living life to the maximum, but instead you have to live in a warden-controlled flat and it’s all because of the booze. I’ve just been speaking to you family, Joy. You have a great family that love you and that care for you and that worry about you. Do you know how lucky you are to have that? There are people in here, on this ward right now, who would give anything to have a family like yours. Your mother is not a well woman and she’s making herself ill because she’s worried sick about you Joy. Do you think that’s fair? Do you think it’s fair that she has to come round and clean up after you when you’re drunk, to make sure you’ve eaten? You’re a grown woman for Christ’s sake. Why are you doing this to her? She’s in her seventies! Why are you doing this to yourself? If you don’t stop drinking Joy, you are going to die. Don’t think I’m saying that just to scare you, I’ve seen it happen so often – it’s the truth. But it doesn’t have to be like that. Your legs will get better if you stop the booze. All this will get better if you stop the booze. You could be out enjoy life if you stop the booze, but you’ve got to want to stop, Joy. The only person who can make this better is you, so you have to ask yourself – What do you want to do?”

By this time, Joy is in tears and she says

“I’m an idiot, aren’t I doctor”

“Yes you are. It’s time to change”

I don’t feel great about upsetting my patient and making her cry, but selfish, manipulative people like her make me so angry, especially because so many people are trying to help her and she’s throwing it all back in everyone’s faces.

What do you think? Was I too harsh? Does my lack of sympathy for Joy make me a bad person? Does it make me a bad doctor?

Not really harsh. I'd say it was tough love. Also, since it sounds like she was starting to think about what she was doing to herself (moving from "pre-contemplative" to "contemplative" if you want to use the fancy jargon of substance abuse models) then it may well have been a good time to strike while the iron's hot and point out what she's doing to herself.

Whether it'll make any difference is anyone's guess. But that's for her to decide.

it makes you a great doctor. sometimes people need to be pushed to start thinking about the things that really matter - just patching people up and sending them on their way isn't really helping, and you signed up so that you could help people.

ruairdh - your father's tale has actually given me some hope. Some hope that people sometimes DO change. Congratulations to you father.

luna - i never asked that question, to be honest her easons for starting didn't interest me, I was just trying to mak her see the reasons for stopping. Stuff like AA is really helpful but ONLY if the person wants to change. If they have no desire to quit, then there's nothing that others can do to help them.

surly girl and spirit of 76 thanks. I really do hope that Joy decides to change. Whether she does or not - who knows? She's lucky to still have her family around her and I'm just hopng I made her see that.

I'm a final year student, and to be honest, I hope I never talk to a patient like that. Yeah, blah blah blah tough love, but to me that sounds like a good excuse for a dose of old-fashioned, hideous paternalism and moralising. Your patient probably doesn't need her face rubbed in the mess of her life, it's only likely to compound whatever emotional crap she is using drink as an escape mechanism from. I really like your blog and think you sound like an ace doctor (and everyone is to be forgiven for moments of getting annoyed with patients) so don't think I'm being mean, it's just my viewpoint on how I'd approach it.